Skip to main content
NCBI home page
NIHPA Author Manuscripts logoLink to NIHPA Author Manuscripts
. Author manuscript; available in PMC: 2017 Dec 1.
Published in final edited form as: Eat Behav. 2016 Jul 15;23:66–69. doi: 10.1016/j.eatbeh.2016.07.003

A Test to Identify Persistent Picky Eaters

Hannah Toyama 1, W Stewart Agras 1
PMCID: PMC5124503  NIHMSID: NIHMS808862  PMID: 27504983

Abstract

Background

Picky eating is common and usually relatively brief as new foods are accepted. Persistent picky eating, however, is often associated with comorbid psychopathology.

Objective

The aim of this study was to use parent-reported child feeding behaviors to identify which picky eaters persist.

Design

Participants were a subsample from the Stanford Infant Growth Study a prospective study of child development. Out of the 216 infants, 86 were identified as picky eaters. Picky eaters were separated into two groups using a median split: short-term (n=40) and persistent picky eaters (n=46).

Results

Recursive Partitioning detected three significant parent-reported feeding questions that may identify persistent picky eaters at an early age: Is your child a picky eater? (yes), does s/he have strong likes with regard to food (yes), does your child accept new foods readily? (no).

Discussion

These results provide a first step allowing providers to identify persistent picky eaters and possibly enable intervention at an early age. Further studies are needed to replicate and extend these findings in another sample of picky eaters.

Keywords: Picky eating, Child, Persistent, Feeding behaviors

1. Introduction

Picky eating is a common problem among children and often stressful for parents (Dubois, Farmer, Girard, et al., 2007a; Nicklaus, Boggio, Chabanet, & Issanchou, 2005). A variety of terms have been used to define the disorder including: picky eating, selective eating, neophobia, sensory food aversion, faddy or fussy eating. However as Bryant-Waugh et al. note (Bryant-Waugh, Markham, Kreipe, & Walsh, 2010), it is difficult to distinguish between such terms. Others (Dovey, Staples, Gibson, & Halford, 2008) suggest that the term neophobia should be reserved for children who refuse to eat novel foods whereas individuals with picky eating refuse many familiar foods as well as novel foods, i.e. picky eating consists of eating a restricted range of familiar foods along with a refusal to eat novel foods. While most children with picky eating show transient symptoms, probably reflecting a normal developmental process, a proportion of picky eaters persist into adolescence and even adulthood (Kauer, Pelchat, Rozin, & Zickgraf, 2015; Mascola, Bryson, & Agras, 2010).

Studies show consistent patterns of behaviors associated with picky eating including: avoidance of familiar foods, lack of consumption of vegetables and/or fruits, refusal to try new foods and consuming less fat and fewer calories than non-picky eaters (Dubois, Farmer, Girard, et al., 2007b; Horodynski, Stommel, Brophy-Herb, Xie, & Weatherspoon, 2010; Jacobi, Schmitz, & Agras, 2008). These problematic behaviors are often associated with caregiver stress, negatively impacting family relationships and often pose a problem for pediatricians (Goh & Jacob, 2012). Persistent picky eating is related to a range of health concerns, behavior problems, and comorbid psychopathology that occur later in childhood and adolescence (Dubois, Farmer, Girard, et al., 2007b; Equit et al., 2013; Jacobi et al., 2008; Lewinsohn et al., 2005; Li, Shi, Wan, Hotta, & Ushijima, 2001; Mascola et al., 2010; Micali et al., 2011; Zucker et al., 2015). Health concerns include: underweight, poor nutrition (Dubois, Farmer, Girard, et al., 2007a) and behavioral problems such as tantrums, withdrawal, somatic complaints, anxiety and depression and higher levels of aggressive, oppositional or delinquent behaviors (Bryant-Waugh et al., 2010; Equit et al., 2013; Mascola et al., 2010). In addition, picky eating appears to be related to eating disorders. In one of the first studies (Marchi & Cohen, 1990) investigated the relationship between children’s maladaptive eating behaviors and eating disorders. Behaviors such as food avoidance, eating too little, and eating too slowly persisted into adolescence. Problem meals and pica in early childhood were found to increase the risk for BN in adolescence and picky eating in early childhood was associated with symptoms of anorexia nervosa in later adolescence. Kotler et al., (2001) found that eating conflicts, struggles with family meals and unpleasant meals, all problems associated with picky eating, were risk factors for the development of eating disorders in adolescence.

Given these problems associated with picky eating that persist, it may be helpful for health care providers to identify such children early in the course of picky eating in order to provide early treatment. To address this issue we examined parent-reported feeding variables to identify persistent picky eating by examining a cohort of infants followed longitudinally from ages 2–11 years old.

2. Method

2.1 Participants

The study was approved by the Stanford University human subjects committee and all parents consented to participate after being fully informed of the study requirements. The participants were a subsample from the Stanford Infant Growth Study (Agras, Hammer, McNicholas, & Kraemer, 2004). Of the 216 infants and their parents enrolled in the study, 40% (n=86) were identified as picky eaters (Jacobi, Agras, Bryson, & Hammer, 2003).

2.2 Assessments

2.2.1. Picky eating

Beginning at 2-years of age at each annual assessment (except for years 8 and 10) a parent (usually mother) was asked, “Is your child a picky eater?” To be considered a picky eater, parents had to report at least “often or always,” a score of 4 or 5 out of a 5 point scale. Scores of 4 or 5 were recoded as “yes” and scores 1–3 were recoded as “no.” This method of identifying picky eaters was validated in a previous study (Jacobi et al., 2003) by comparing the eating behaviors of picky and non-picky eaters in a laboratory meal and finding that picky eaters ate fewer foods and avoided vegetables compared with non-picky eaters. In addition, picky girls ate fewer calories than non-picky girls. The duration of picky eating was calculated by counting the number of years for which picky eating, as defined above, was present. Missing data on the presence of picky eating over time was interpolated for 4 participants for 1 assessment point each.

2.2.2. Child and parent feeding behaviors

The Stanford Feeding Questionnaire was administered at each assessment as described above. Questions assessed feeding behaviors including items such as a limited variety of foods, food prepared in specific ways, accepts new foods readily, has strong likes, dislikes, etc (Mascola et al., 2010). Some questions used a yes/no response, while others used a scale of 1–5 (1=Never, 2=Rarely, 3=Sometimes, 4=Often, 5=Always). Thus to keep the response formats consistent, the responses were recoded to yes/no using the same rule as for the picky eating question.

2.3 Statistical analysis

There is no existing clinical definition to distinguish between short and long term picky eaters; therefore, we dichotomized total picky eating years using a median split to maximize power (Kraemer & Thiemann, 1987). The resulting binary outcome defined those children with 3 or more years of picky eating (persistent picky eaters) and those with 2 or less years of picky eating (short term picky eaters). In the persistent group of picky eaters, duration of picky eating ranged from 3–10 years (M = 5.54, SD = 2.40) and short-term picky eaters, duration ranged from 1–2 years (M = 1.18, SD = .385). A Chi-square test was used to examine the association between each feeding behavior and the binary outcome. Feeding behaviors found statistically significant (p<.05) were then used in a signal detection procedure (Kraemer, 1992) (a type of recursive partitioning) to characterize the sample and determine which sub-groups were more likely to be picky eaters. The analysis was carried out using The Signal Detection Software for Receiver Operator Charcteristics (ROC), which produces a decision tree and the stopping rules are defined by marginal cell sizes and p-values. Recursive partitioning was used to better understand which sub-groups in the sample were more likely to be frequent picky eaters. An ROC curve is shown in Figure 1.

Figure 1.

Figure 1

Open in a new tab

Sensitivity and specificity of the predictor variables showing the area under curve (AUC= 0.73).

3. Results

3.1. Demographic Characteristics

Out of the 86 picky eaters, there were 34 females (39.5%) and 52 males (60.5%). The mother’s age ranged from 25.1 to 42.7 years (M = 32.57, SD = 3.71), father’s from 24.76 to 48.9 years (M = 48.49, SD = 4.68). Mother’s ethnicities included 89.5% Caucasian, 4.7% Asian, 4.7% Hispanic, and 1.2% Pacific Islander. Father’s ethnicities included 89.5% Caucasian, 8.1% Asian, and 2.3% Hispanic. The majority of the mothers completed graduate school or college (77.9%); the remainder completed some college, high school, and some high school (22.2%). The majority of fathers also completed graduate school or college (77.9%) and the remaining completed some college and high school (21.1%). Mother’s BMI ranged from 19.03 to 38.65 (M = 23.85, SD = 3.99) and father’s BMI from 19.92 to 34.33 (M = 25.55, SD = 3.06). The majority of the parents were born in the U.S.A (70.9%).

A median split of total picky years resulted in 46 children categorized as persistent (n=46) and 40 as short term picky eaters. Table 1 shows the 18 parent-reported feeding behaviors taken from the Stanford Feeding Questionnaire. Three of the child feeding behaviors was significantly associated with the binary outcome of persistent vs. short-term picky eaters and these three variables were subsequently used in the recursive-partitioning model.

Table 1.

Parent-reported feeding behavior variables

Feeding Behavior Variables First Response Yesa
X2
Short Term
n=40		 Long Term
n=46
Parent behaviors
Frequent struggles over food 10(25%) 13(28.3%) .116
Argue with spouse about child’s eating 2(5%) 11(23.9%) 5.964
Verbally encourage if child doesn’t eat 19(47.5%) 35(76.1%) 7.484**
Offer reward if child doesn’t eat 6(15%) 16(34.8%) 4.398*
Threaten if child doesn’t eat 0(0%) 1(2.2%) .880
Do nothing if child doesn’t eat 3(7.5%) 11(23.9%) 4.229*
Limit sweets 7(17.5%) 10(21.7%) .242
Limit non-sweets 1(2.5%) 0(0%) 1.164
Prepare separate meal for child 2(5%) 9(19.6%) 4.069*
Child has tantrums when parents say no to food 12(30%) 26(56.5%) 6.102*
Child eating behaviors
Has strong likes 19(47.5%) 38(82.6%) 11.800***
Is a fast eater 4(10%) 7(15.2%) 0.522
Is a slow eater 18(45%) 20(43.5%) .02
Limited variety of foods 16(40%) 32(69.6%) 7.583**
Food prepared in specific ways 12(30%) 20(43.5%) 1.664
Accepts new foods readily 18(45%) 9(19.6%) 6.426*
Has strong dislikes 23(57.5%) 34(73.9%) 2.579
Open in a new tab
a

First response yes refers to the earliest age that the child was reported picky and responded “yes” to the parent reported feeding behaviors.

*

p ≤ 0.05

**

p ≤ 0.01

***

p ≤ 0.001

The ROC decision tree is shown in Figure 2. At the initial split, strong likes was selected as the optimal variable dividing picky eaters into persistent or not. Strong likes was identified if the participant’s parents answered, “yes” to the question, “does s/he have strong likes with regard to food?” Among those with strong likes, the next optimal cut point was whether the child accepted new foods. Those who had strong likes and did not accept new foods were identified as persistent picky eaters as shown in Figure 2. Children whose parent reported strong likes and did not accept new foods were more likely to be persistent picky eaters (75.6%). About half (43.8%) of children who reported strong likes and accepted new food were likely to be persistent picky eaters. Children who did not report strong likes were least likely to be persistent picky eaters (27.6%). Figure 1 shows the ROC curve, which plots the model sensitivity (true positive rate) as a function of the specificity (false positive rate). The accuracy of the model is represented by the AUC, which is 0.73 (95%CI=0.63, 0.83) as shown in Figure 1.

Figure 2.

Figure 2

Open in a new tab

Results of the recursive partitioning showing the two significant predictor variables: strong food likes and food acceptance.

4. Discussion

Our findings suggest that three questions posed to parents can identify persistent picky eaters: Is your child a picky eater? (Yes), does s/he have strong likes with regard to food? (Yes), and does your child accept new foods readily? (No). This test had an acceptable accuracy as shown by AUC of 0.73. Given that persistent picky eating is associated with considerable comorbid psychopathology and with much family disturbance (Goh & Jacob, 2012; Micali et al., 2011) identifying subgroups with higher risk of becoming persistent picky eaters would allow clinicians to distinguish those who may need treatment from those who will not. However this study has its limitations. First, the parents were well educated and the sample size is relatively small. Therefore, we could not perform model validation. Hence, replication and extension of these results is needed in a different and larger sample. However, the longitudinal nature of the study is a strength allowing the development of a test to predict outcomes. These findings are a first step in providing useful information to enable providers to identify persistent and therefore more severe picky eater, enabling intervention at an early age.

Highlights.

  • Persistent picky eating is associated with comorbid psychopathology.

  • Feeding behaviors were used to prospectively identify persistent picky eaters.

  • Three of 18 feeding behavior questions were significantly associated with persistent picky eaters.

Acknowledgments

This study was supported in part by a grant from the National Institute of Child Health and Development (HD25492).

Role of funding sources

Funding for this study was provided by the National Institute of Child Health and Development HD25492. The funders played no role in the study design, data collection, data analysis or interpretation of the data, writing the manuscript, or the decision to submit the paper for publication.

Footnotes

Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

Contributors

SA designed the study and oversaw the analysis and preparation of the paper. HT conducted literature searches, played a major role in data analysis, data interpretation and writing the paper in full. Both authors contributed to and approved the final draft.

Conflict of interest

All Authors declare that they have no conflicts of interest.

References

  1. Agras WS, Hammer LD, McNicholas F, Kraemer HC. Risk factors for childhood overweight: a prospective study from birth to 9.5 years. J Pediatr. 2004;145(1):20–25. doi: 10.1016/j.jpeds.2004.03.023. [DOI] [PubMed] [Google Scholar]
  2. Bryant-Waugh R, Markham L, Kreipe RE, Walsh BT. Feeding and eating disorders in childhood. Int J Eat Disord. 2010;43(2):98–111. doi: 10.1002/eat.20795. [DOI] [PubMed] [Google Scholar]
  3. Dovey TM, Staples PA, Gibson EL, Halford JCG. Food neophobia and picky/fussy eating in children: A review. Appetite. 2008;50:181–193. doi: 10.1016/j.appet.2007.09.009. [DOI] [PubMed] [Google Scholar]
  4. Dubois L, Farmer A, Girard M, Peterson K, Tatone-Tokuda F. Problem eating behaviors related to social factors and body weight in preschool children: A longitudinal study. Int J Behav Nutr Phys Act. 2007a;4:9. doi: 10.1186/1479-5868-4-9. [DOI] [PMC free article] [PubMed] [Google Scholar]
  5. Dubois L, Farmer AP, Girard M, Peterson K. Preschool children’s eating behaviours are related to dietary adequacy and body weight. Eur J Clin Nutr. 2007b;61(7):846–855. doi: 10.1038/sj.ejcn.1602586. [DOI] [PubMed] [Google Scholar]
  6. Equit M, Palmke M, Becker N, Moritz AM, Becker S, von Gontard A. Eating problems in young children – a population-based study. Acta Paediatr. 2013;102(2):149–155. doi: 10.1111/apa.12078. [DOI] [PubMed] [Google Scholar]
  7. Goh DY, Jacob A. Perception of picky eating among children in Singapore and its impact on caregivers: a questionnaire survey. Asia Pac Fam Med. 2012;11(1):5. doi: 10.1186/1447-056X-11-5. [DOI] [PMC free article] [PubMed] [Google Scholar]
  8. Horodynski MA, Stommel M, Brophy-Herb H, Xie Y, Weatherspoon L. Low-income African American and non-Hispanic White mothers’ self-efficacy, “picky eater” perception, and toddler fruit and vegetable consumption. Public Health Nurs. 2010;27(5):408–417. doi: 10.1111/j.1525-1446.2010.00873.x. [DOI] [PubMed] [Google Scholar]
  9. Jacobi C, Agras WS, Bryson S, Hammer LD. Behavioral validation, precursors, and concomitants of picky eating in childhood. J Am Acad Child Adolesc Psychiatry. 2003;42(1):76–84. doi: 10.1097/00004583-200301000-00013. [DOI] [PubMed] [Google Scholar]
  10. Jacobi C, Schmitz G, Agras WS. Is picky eating an eating disorder? Int J Eat Disord. 2008;41(7):626–634. doi: 10.1002/eat.20545. [DOI] [PubMed] [Google Scholar]
  11. Kauer J, Pelchat ML, Rozin P, Zickgraf HF. Adult picky eating. Phenomenology, taste sensitivity, and psychological correlates. Appetite. 2015;90:219–228. doi: 10.1016/j.appet.2015.03.001. [DOI] [PMC free article] [PubMed] [Google Scholar]
  12. Kotler LA, Cohen P, Davies M, Pine DS, Walsh BT. Longitudinal relationships between childhood, adolescent, and adult eating disorders. J Am Acad Child Adolesc Psychiatry. 2001;40(12):1434–1440. doi: 10.1097/00004583-200112000-00014. [DOI] [PubMed] [Google Scholar]
  13. Kraemer HC. Evaluating Medical Tests: Objective and Quantitative Guidelines. Newbury Park, CA: Sage; 1992. [Google Scholar]
  14. Kraemer HC, T S. How Many Subjects?: Statistical Power Analysis in Research. 1. Thousand Oaks, CA, US: Sage Publications, Inc; 1987. [Google Scholar]
  15. Lewinsohn PM, Holm-Denoma JM, Gau JM, Joiner TE, Jr, Striegel-Moore R, Bear P, Lamoureux B. Problematic eating and feeding behaviors of 36-month-old children. Int J Eat Disord. 2005;38(3):208–219. doi: 10.1002/eat.20175. [DOI] [PMC free article] [PubMed] [Google Scholar]
  16. Li Y, Shi A, Wan Y, Hotta M, Ushijima H. Child behavior problems: prevalence and correlates in rural minority areas of China. Pediatr Int. 2001;43(6):651–661. doi: 10.1046/j.1442-200x.2001.01446.x. [DOI] [PubMed] [Google Scholar]
  17. Marchi M, Cohen P. Early childhood eating behaviors and adolescent eating disorders. J Am Acad Child Adolesc Psychiatry. 1990;29(1):112–117. doi: 10.1097/00004583-199001000-00017. [DOI] [PubMed] [Google Scholar]
  18. Mascola AJ, Bryson SW, Agras WS. Picky eating during childhood: a longitudinal study to age 11 years. Eat Behav. 2010;11(4):253–257. doi: 10.1016/j.eatbeh.2010.05.006. [DOI] [PMC free article] [PubMed] [Google Scholar]
  19. Micali N, Simonoff E, Elberling H, Rask CU, Olsen EM, Skovgaard AM. Eating patterns in a population-based sample of children aged 5 to 7 years: association with psychopathology and parentally perceived impairment. J Dev Behav Pediatr. 2011;32(8):572–580. doi: 10.1097/DBP.0b013e31822bc7b7. [DOI] [PubMed] [Google Scholar]
  20. Nicklaus S, Boggio V, Chabanet C, Issanchou S. A prospective study of food variety seeking in childhood, adolescence and early adult life. Appetite. 2005;44(3):289–297. doi: 10.1016/j.appet.2005.01.006. [DOI] [PubMed] [Google Scholar]
  21. Zucker N, Copeland W, Franz L, Carpenter K, Keeling L, Angold A, Egger H. Psychological and Psychosocial Impairment in Preschoolers With Selective Eating. Pediatrics. 2015 doi: 10.1542/peds.2014-2386. [DOI] [PMC free article] [PubMed] [Google Scholar]

RESOURCES